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ERROR: type should be string, got "https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly93d3cubWVkc2NhcGUuY29tL2Fuc3dlcnMvMzMyOTQ1LTcwMDc5L2hvdy1pcy11bmRpZmZlcmVudGlhdGVkLXNwb25keWxvYXJ0aHJvcGF0aHktdXNwYS1kaWFnbm9zZWQ=\nDrugs & Diseases > Rheumatology > Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy Q&A\nHow is undifferentiated spondyloarthropathy (USpA) diagnosed?\nAuthor: Lawrence H Brent, MD; Chief Editor: Herbert S Diamond, MD more...\nThe age of onset for USpA extends over a very wide range, with the peak onset at approximately age 50 years. The male-to-female ratio is 1:3. The onset is usually insidious, and, even after years of active disease, sacroiliitis and spondylitis are either absent or appear very mild on routine radiography.\nClinical manifestations of undifferentiated spondyloarthropathy include inflammatory back pain, buttock pain, enthesitis, peripheral arthritis, dactylitis, and fatigue (see Table 4 below). Extra-articular manifestations are uncommon, occurring in fewer than 10% of patients, and include acute anterior uveitis (1-2%), oral ulcers, rash, nonspecific IBD, pleuritis, and pericarditis.\nTable 4. Clinical and Laboratory Features of Undifferentiated Spondyloarthropathy (Open Table in a new window)\nClinical or Laboratory Feature\nInflammatory back pain\nEnthesitis\nPeripheral arthritis\nDactylitis (sausage digits)\nAcute anterior uveitis\nElevated ESR\nHLA-B27 positive\nESR = erythrocyte sedimentation rate.\nFindings of laboratory studies are generally unremarkable except for the presence of an elevated ESR or CRP level. HLA-B27 antigen is positive only in approximately 20-25% of patients.\nThese factors, especially the late age of onset, female predominance, and low HLA-B27 positivity, suggest that USpA is distinct from AS and the other classic spondyloarthropathies.\nIn addition, when these patients are observed over long periods, they rarely develop clinical manifestations or radiographic changes that result in a change of diagnosis. Occasionally, radiographs show evidence of periosteal new bone formation at sites of enthesitis, especially at the insertion of the Achilles tendon or plantar fascia on the calcaneus, or early syndesmophytes on the lumbar spine without bridging.\nAlthough most patients with USpA (>75%) have chronic, active disease and require long-term therapy for ongoing symptoms, some patients have mild and intermittent symptoms that require intermittent symptomatic therapy. These episodes may last from 1-2 weeks to several months, with long asymptomatic periods that do not require therapy.\nMost patients respond well to nonsteroidal anti-inflammatory drugs (NSAIDs). The majority maintain good function without progressive disease or clinically significant radiographic changes. A small minority of patients do not respond well to or tolerate NSAIDs. In these patients, treatment progression is similar to that in AS patients, including the use of sulfasalazine, methotrexate, and tumor necrosis factor alpha (TNF-α) antagonists, although no well-designed clinical trials have been conducted on the treatment of USpA.\nPassalent LA, Soever LJ, O'Shea FD, Inman RD. Exercise in ankylosing spondylitis: discrepancies between recommendations and reality. J Rheumatol. 2010 Apr. 37(4):835-41. [Medline].\nJones SD, Koh WH, Steiner A, Garrett SL, Calin A. Fatigue in ankylosing spondylitis: its prevalence and relationship to disease activity, sleep, and other factors. J Rheumatol. 1996 Mar. 23(3):487-90. [Medline].\nMengshoel AM, Førre O. Pain and fatigue in patients with rheumatic disorders. Clin Rheumatol. 1993 Dec. 12(4):515-21. [Medline].\nvan der Linden S, van der Heijde D. Ankylosing spondylitis. Clinical features. Rheum Dis Clin North Am. 1998 Nov. 24(4):663-76, vii. [Medline].\nCollantes-Estevez E, Cisnal del Mazo A, Munoz-Gomariz E. Assessment of 2 systems of spondyloarthropathy diagnostic and classification criteria (Amor and ESSG) by a Spanish multicenter study. European Spondyloarthropathy Study Group. J Rheumatol. 1995 Feb. 22(2):246-51. [Medline].\nDougados M, van der Linden S, Juhlin R, et al. The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy. Arthritis Rheum. 1991 Oct. 34(10):1218-27. [Medline].\nvan der Heijde D, Spoorenberg A. Plain radiographs as an outcome measure in ankylosing spondylitis. J Rheumatol. 1999 Apr. 26(4):985-7. [Medline].\nNaredo E, Batlle-Gualda E, García-Vivar ML, García-Aparicio AM, Fernández-Sueiro JL, Fernández-Prada M, et al. Power Doppler ultrasonography assessment of entheses in spondyloarthropathies: response to therapy of entheseal abnormalities. J Rheumatol. 2010 Oct. 37(10):2110-7. [Medline].\nVinson EN, Major NM. MR imaging of ankylosing spondylitis. Semin Musculoskelet Radiol. 2003 Jun. 7(2):103-13. [Medline].\nGeijer M, Gothlin GG, Gothlin JH. The clinical utility of computed tomography compared to conventional radiography in diagnosing sacroiliitis. A retrospective study on 910 patients and literature review. J Rheumatol. 2007 Jul. 34(7):1561-5. [Medline].\nVan Royen BJ, De Gast A. Lumbar osteotomy for correction of thoracolumbar kyphotic deformity in ankylosing spondylitis. A structured review of three methods of treatment. Ann Rheum Dis. 1999 Jul. 58(7):399-406. [Medline]. [Full Text].\nShih LY, Chen TH, Lo WH, Yang DJ. Total hip arthroplasty in patients with ankylosing spondylitis: longterm followup. J Rheumatol. 1995 Sep. 22(9):1704-9. [Medline].\nCawley MI, Chalmers TM, Ball J. Destructive lesions of vertebral bodies in ankylosing spondylitis. Ann Rheum Dis. 1971 Sep. 30(5):539-40. [Medline]. [Full Text].\nHanson JA, Mirza S. Predisposition for spinal fracture in ankylosing spondylitis. AJR Am J Roentgenol. 2000 Jan. 174(1):150. [Medline].\nHunter T. The spinal complications of ankylosing spondylitis. Semin Arthritis Rheum. 1989 Dec. 19(3):172-82. [Medline].\nSutherland RI, Matheson D. Inflammatory involvement of vertebrae in ankylosing spondylitis. J Rheumatol. 1975 Sep. 2(3):296-302. [Medline].\nvan der Linden S, van der Heijde D. Clinical aspects, outcome assessment, and management of ankylosing spondylitis and postenteric reactive arthritis. Curr Opin Rheumatol. 2000 Jul. 12(4):263-8. [Medline].\nSchlosstein L, Terasaki PI, Bluestone R, et al. High association of an HL-A antigen, W27, with ankylosing spondylitis. N Engl J Med. 1973 Apr 5. 288(14):704-6. [Medline].\nBrewerton DA, Hart FD, Nicholls A, Caffrey M, James DC, Sturrock RD. Ankylosing spondylitis and HL-A 27. Lancet. 1973 Apr 28. 1(7809):904-7. [Medline].\nCaffrey MF, James DC. Human lymphocyte antigen association in ankylosing spondylitis. Nature. 1973 Mar 9. 242(5393):121. [Medline].\nAlvarez I, López de Castro JA. HLA-B27 and immunogenetics of spondyloarthropathies. Curr Opin Rheumatol. 2000 Jul. 12(4):248-53. [Medline].\nMcGonagle D, Gibbon W, Emery P. Classification of inflammatory arthritis by enthesitis. Lancet. 1998 Oct 3. 352(9134):1137-40. [Medline].\nMuñoz-Villanueva MC, Muñoz-Gomariz E, Escudero-Contreras A, et al. Biological and clinical markers of disease activity in ankylosing spondylitis. J Rheumatol. 2003 Dec. 30(12):2729-32. [Medline]. [Full Text].\nPalazzi C, Olivieri I, D'Amico E, Pennese E, Petricca A. Management of reactive arthritis. Expert Opin Pharmacother. 2004 Jan. 5(1):61-70. [Medline].\nMcGonagle D, Emery P. Enthesitis, osteitis, microbes, biomechanics, and immune reactivity in ankylosing spondylitis. J Rheumatol. 2000 Oct. 27(10):2302-4. [Medline].\nO'Neill TW, Bresnihan B. The heart in ankylosing spondylitis. Ann Rheum Dis. 1992 Jun. 51(6):705-6. [Medline]. [Full Text].\nKhan MA. Update on spondyloarthropathies. Ann Intern Med. 2002 Jun 18. 136(12):896-907. [Medline].\nWordsworth P. Genes in the spondyloarthropathies. Rheum Dis Clin North Am. 1998 Nov. 24(4):845-63. [Medline].\nReveille JD. The genetic basis of ankylosing spondylitis. Curr Opin Rheumatol. 2006 Jul. 18(4):332-41. [Medline].\nBrionez TF, Reveille JD. The contribution of genes outside the major histocompatibility complex to susceptibility to ankylosing spondylitis. Curr Opin Rheumatol. 2008 Jul. 20(4):384-91. [Medline].\nBrown MA. Breakthroughs in genetic studies of ankylosing spondylitis. Rheumatology (Oxford). 2008 Feb. 47(2):132-7. [Medline].\nReveille JD, Ball EJ, Khan MA. HLA-B27 and genetic predisposing factors in spondyloarthropathies. Curr Opin Rheumatol. 2001 Jul. 13(4):265-72. [Medline].\nJaakkola E, Herzberg I, Laiho K, Barnardo MC, Pointon JJ, Kauppi M, et al. Finnish HLA studies confirm the increased risk conferred by HLA-B27 homozygosity in ankylosing spondylitis. Ann Rheum Dis. 2006 Jun. 65(6):775-80. [Medline].\nReveille JD, Arnett FC. Spondyloarthritis: update on pathogenesis and management. Am J Med. 2005 Jun. 118(6):592-603. [Medline].\nvan Gaalen FA, Verduijn W, Roelen DL, Böhringer S, Huizinga TW, van der Heijde DM, et al. Epistasis between two HLA antigens defines a subset of individuals at a very high risk for ankylosing spondylitis. Ann Rheum Dis. 2012 Aug 21. [Medline].\nEbringer A. The relationship between Klebsiella infection and ankylosing spondylitis. Baillieres Clin Rheumatol. 1989 Aug. 3(2):321-38. [Medline].\nTimms AE, Crane AM, Sims AM, Cordell HJ, Bradbury LA, Abbott A, et al. The interleukin 1 gene cluster contains a major susceptibility locus for ankylosing spondylitis. Am J Hum Genet. 2004 Oct. 75(4):587-95. [Medline].\nMaksymowych WP, Rahman P, Reeve JP, Gladman DD, Peddle L, Inman RD. Association of the IL1 gene cluster with susceptibility to ankylosing spondylitis: an analysis of three Canadian populations. Arthritis Rheum. 2006 Mar. 54(3):974-85. [Medline].\nBurton PR, Clayton DG, Cardon LR, Craddock N, Deloukas P, Duncanson A, et al. Association scan of 14,500 nonsynonymous SNPs in four diseases identifies autoimmunity variants. Nat Genet. 2007 Nov. 39(11):1329-37. [Medline].\nRahman P, Inman RD, Gladman DD, Reeve JP, Peddle L, Maksymowych WP. Association of interleukin-23 receptor variants with ankylosing spondylitis. Arthritis Rheum. 2008 Apr. 58(4):1020-5. [Medline].\nRueda B, Orozco G, Raya E, Fernandez-Sueiro JL, Mulero J, Blanco FJ, et al. The IL23R Arg381Gln non-synonymous polymorphism confers susceptibility to ankylosing spondylitis. Ann Rheum Dis. 2008 Oct. 67(10):1451-4. [Medline].\nKaraderi T, Harvey D, Farrar C, Appleton LH, Stone MA, Sturrock RD, et al. Association between the interleukin 23 receptor and ankylosing spondylitis is confirmed by a new UK case-control study and meta-analysis of published series. Rheumatology (Oxford). 2009 Apr. 48(4):386-9. [Medline].\nLayh-Schmitt G, Colbert RA. The interleukin-23/interleukin-17 axis in spondyloarthritis. Curr Opin Rheumatol. 2008 Jul. 20(4):392-7. [Medline].\nHammer RE, Maika SD, Richardson JA, et al. Spontaneous inflammatory disease in transgenic rats expressing HLA-B27 and human beta 2m: an animal model of HLA-B27-associated human disorders. Cell. 1990 Nov 30. 63(5):1099-112. [Medline].\nKhare SD, Luthra HS, David CS. Animal models of human leukocyte antigen B27-linked arthritides. Rheum Dis Clin North Am. 1998 Nov. 24(4):883-94, xi-xii. [Medline].\nLories RJ. Animal models of spondyloarthritis. Curr Opin Rheumatol. 2006 Jul. 18(4):342-6. [Medline].\nBraun J, Bollow M, Remlinger G, et al. Prevalence of spondylarthropathies in HLA-B27 positive and negative blood donors. Arthritis Rheum. 1998 Jan. 41(1):58-67. [Medline].\nTrontzas P, Andrianakos A, Miyakis S, et al. Seronegative spondyloarthropathies in Greece: a population-based study of prevalence, clinical pattern, and management. The ESORDIG study. Clin Rheumatol. 2005 Nov. 24(6):583-9. [Medline].\nDe Angelis R, Salaffi F, Grassi W. Prevalence of spondyloarthropathies in an Italian population sample: a regional community-based study. Scand J Rheumatol. 2007 Jan-Feb. 36(1):14-21. [Medline].\nTaurog JD. The mystery of HLA-B27: if it isn't one thing, it's another. Arthritis Rheum. 2007 Aug. 56(8):2478-81. [Medline].\nBraun J, Sieper J. Ankylosing spondylitis. Lancet. 2007 Apr 21. 369(9570):1379-90. [Medline].\nFeldtkeller E, Khan MA, van der Heijde D, et al. Age at disease onset and diagnosis delay in HLA-B27 negative vs. positive patients with ankylosing spondylitis. Rheumatol Int. 2003 Mar. 23(2):61-6. [Medline].\nDincer U, Cakar E, Kiralp MZ, Dursun H. Diagnosis delay in patients with ankylosing spondylitis: possible reasons and proposals for new diagnostic criteria. Clin Rheumatol. 2008 Apr. 27(4):457-62. [Medline].\nRezaian MM, Brent LH. Undifferentiated spondyloarthropathy: Seven-year follow-up study of 357 patients. Arthritis Rheum. 2001. 44:S93.\nLee W, Reveille JD, Davis JC Jr, et al. Are there gender differences in severity of ankylosing spondylitis? Results from the PSOAS cohort. Ann Rheum Dis. 2007 May. 66(5):633-8. [Medline].\nSingh DK, Magrey M. Racial Differences in Clinical Features and Co-morbidities In Ankylosing Spondylitis in the United States. J Rheumatol. 2019 Sep 1. [Medline].\nBraun J, Pincus T. Mortality, course of disease and prognosis of patients with ankylosing spondylitis. Clin Exp Rheumatol. 2002 Nov-Dec. 20(6 Suppl 28):S16-22. [Medline].\nRingsdal VS, Helin P. Ankylosing spondylitis--education, employment and invalidity. Dan Med Bull. 1991 Jun. 38(3):282-4. [Medline].\nWordsworth BP, Mowat AG. A review of 100 patients with ankylosing spondylitis with particular reference to socio-economic effects. Br J Rheumatol. 1986 May. 25(2):175-80. [Medline].\nMcGuigan LE, Hart HH, Gow PJ, Kidd BL, Grigor RR, Moore TE. Employment in ankylosing spondylitis. Ann Rheum Dis. 1984 Aug. 43(4):604-6. [Medline]. [Full Text].\nLehtinen K. Working ability of 76 patients with ankylosing spondylitis. Scand J Rheumatol. 1981. 10(4):263-5. [Medline].\nVerstappen SM, Watson KD, Lunt M, McGrother K, Symmons DP, Hyrich KL. Working status in patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis: results from the British Society for Rheumatology Biologics Register. Rheumatology (Oxford). 2010 Aug. 49(8):1570-7. [Medline]. [Full Text].\nGran JT, Skomsvoll JF. The outcome of ankylosing spondylitis: a study of 100 patients. Br J Rheumatol. 1997 Jul. 36(7):766-71. [Medline].\nGuillemin F, Briançon S, Pourel J, Gaucher A. Long-term disability and prolonged sick leaves as outcome measurements in ankylosing spondylitis. Possible predictive factors. Arthritis Rheum. 1990 Jul. 33(7):1001-6. [Medline].\nLeirisalo-Repo M. Prognosis, course of disease, and treatment of the spondyloarthropathies. Rheum Dis Clin North Am. 1998 Nov. 24(4):737-51, viii. [Medline].\nCarette S, Graham D, Little H, Rubenstein J, Rosen P. The natural disease course of ankylosing spondylitis. Arthritis Rheum. 1983 Feb. 26(2):186-90. [Medline].\nSampaio-Barros PD, Bertolo MB, Kraemer MH, et al. Undifferentiated spondyloarthropathies: a 2-year follow-up study. Clin Rheumatol. 2001. 20(3):201-6. [Medline].\nMattey DL, Dawson SR, Healey EL, Packham JC. Relationship Between Smoking and Patient-reported Measures of Disease Outcome in Ankylosing Spondylitis. J Rheumatol. 2011 Dec. 38(12):2608-15. [Medline].\nO'Shea FD, Riarh R, Anton A, Inman RD. Assessing back pain: does the Oswestry Disability Questionnaire accurately measure function in ankylosing spondylitis?. J Rheumatol. 2010 Jun. 37(6):1211-3. [Medline].\nCalin A, Porta J, Fries JF, et al. Clinical history as a screening test for ankylosing spondylitis. JAMA. 1977 Jun 13. 237(24):2613-4. [Medline].\nRudwaleit M, Metter A, Listing J, et al. Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis Rheum. 2006 Feb. 54(2):569-78. [Medline].\nSieper J, van der Heijde D, Landewé R, Brandt J, Burgos-Vagas R, Collantes-Estevez E, et al. New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis international Society (ASAS). Ann Rheum Dis. 2009 Jun. 68 (6):784-8. [Medline].\nMartin TM, Smith JR, Rosenbaum JT. Anterior uveitis: current concepts of pathogenesis and interactions with the spondyloarthropathies. Curr Opin Rheumatol. 2002 Jul. 14(4):337-41. [Medline].\nAli A, Samson CM. Seronegative spondyloarthropathies and the eye. Curr Opin Ophthalmol. 2007 Nov. 18(6):476-80. [Medline].\nBurgos-Vargas R. The juvenile-onset spondyloarthritides. Rheum Dis Clin North Am. 2002 Aug. 28(3):531-60, vi. [Medline].\nTse SM, Laxer RM. Juvenile spondyloarthropathy. Curr Opin Rheumatol. 2003 Jul. 15(4):374-9. [Medline].\nZeidler H, Mau W, Khan MA. Undifferentiated spondyloarthropathies. Rheum Dis Clin North Am. 1992 Feb. 18(1):187-202. [Medline].\nAmor B, Dougados M, Mijiyawa M. [Criteria of the classification of spondylarthropathies]. Rev Rhum Mal Osteoartic. 1990 Feb. 57(2):85-9. [Medline].\nRasker JJ, Prevo RL, Lanting PJ. Spondylodiscitis in ankylosing spondylitis, inflammation or trauma? A description of six cases. Scand J Rheumatol. 1996. 25(1):52-7. [Medline].\nDihlmann W, Delling G. Discovertebral destructive lesions (so called Andersson lesions) associated with ankylosing spondylitis. Skel Radiol. 1978. 3:10-6.\nAgarwal AK, Reidbord HE, Kraus DR, Eisenbeis CH Jr. Variable histopathology of discovertebral lesion (spondylodiscitis) of ankylosing spondylitis. Clin Exp Rheumatol. 1990 Jan-Feb. 8(1):67-9. [Medline].\nLipton S, Deodhar A. The New ASAS Classification Criteria for Axial and Peripheral Spondyloarthritis. Medscape Medical News. Available at http://www.medscape.com/viewarticle/776097_5. Accessed: November 4, 2014.\nRudwaleit M, van der Heijde D, Landewé R, Akkoc N, Brandt J, Chou CT, et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis. 2011 Jan. 70(1):25-31. [Medline].\nRudwaleit M, van der Heijde D, Landewé R, Listing J, Akkoc N, Brandt J, et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis. 2009 Jun. 68 (6):777-83. [Medline].\nvan der Heijde D, Landewé R. Imaging in spondylitis. Curr Opin Rheumatol. 2005 Jul. 17(4):413-7. [Medline].\n[Guideline] Mandl P, Navarro-Compán V, Terslev L, et al. EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice. Ann Rheum Dis. 2015 Apr 2. [Medline]. [Full Text].\nRuof J, Stucki G. Validity aspects of erythrocyte sedimentation rate and C-reactive protein in ankylosing spondylitis: a literature review. J Rheumatol. 1999 Apr. 26(4):966-70. [Medline].\nDougados M, Gueguen A, Nakache JP, et al. Clinical relevance of C-reactive protein in axial involvement of ankylosing spondylitis. J Rheumatol. 1999 Apr. 26(4):971-4. [Medline].\nAnwar F, Al-Khayer A, Joseph G, Fraser MH, Jigajinni MV, Allan DB. Delayed presentation and diagnosis of cervical spine injuries in long-standing ankylosing spondylitis. Eur Spine J. 2011 Mar. 20(3):403-7. [Medline]. [Full Text].\nBaraliakos X, Hermann KG, Landewé R, Listing J, Golder W, Brandt J, et al. Assessment of acute spinal inflammation in patients with ankylosing spondylitis by magnetic resonance imaging: a comparison between contrast enhanced T1 and short tau inversion recovery (STIR) sequences. Ann Rheum Dis. 2005 Aug. 64(8):1141-4. [Medline].\nHermann KG, Landewé RB, Braun J, van der Heijde DM. Magnetic resonance imaging of inflammatory lesions in the spine in ankylosing spondylitis clinical trials: is paramagnetic contrast medium necessary?. J Rheumatol. 2005 Oct. 32(10):2056-60. [Medline].\nKim NR, Choi JY, Hong SH, Jun WS, Lee JW, Choi JA, et al. \"MR corner sign\": value for predicting presence of ankylosing spondylitis. AJR Am J Roentgenol. 2008 Jul. 191(1):124-8. [Medline].\nMaksymowych WP, Chiowchanwisawakit P, Clare T, Pedersen SJ, Østergaard M, Lambert RG. Inflammatory lesions of the spine on magnetic resonance imaging predict the development of new syndesmophytes in ankylosing spondylitis: evidence of a relationship between inflammation and new bone formation. Arthritis Rheum. 2009 Jan. 60(1):93-102. [Medline].\nZochling J, van der Heijde D, Burgos-Vargas R, et al. ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis. 2006 Apr. 65(4):442-52. [Medline].\nHalm H, Metz-Stavenhagen P, Zielke K. Results of surgical correction of kyphotic deformities of the spine in ankylosing spondylitis on the basis of the modified arthritis impact measurement scales. Spine (Phila Pa 1976). 1995 Jul 15. 20(14):1612-9. [Medline].\nHunter T, Dubo HI. Spinal fractures complicating ankylosing spondylitis. A long-term followup study. Arthritis Rheum. 1983 Jun. 26(6):751-9. [Medline].\nCarron P, Varkas G, Renson T, Colman R, Elewaut D, Van den Bosch F. High rate of drug-free remission after induction therapy with golimumab in early peripheral spondyloarthritis. Arthritis Rheumatol. 2018 May 27. [Medline].\nLewis R. TNF Inhibitor Induces Drug-Free Remission in Early Spondyloarthritis. Medscape Medical News. Available at https://www.medscape.com/viewarticle/897894?src=soc_fb_180612_mscpedt_news_mdscp_arthritis&faf=1. June 11, 2018; Accessed: June 12, 2018.\nCimzia (certolizumab) [package insert]. Lake Park Drive Smyrna, GA: UCB, Inc. April 2019. Available at [Full Text].\nEscalas C, Trijau S, Dougados M. Evaluation of the treatment effect of NSAIDs/TNF blockers according to different domains in ankylosing spondylitis: results of a meta-analysis. Rheumatology (Oxford). 2010 Jul. 49(7):1317-25. [Medline].\nWanders A, Heijde D, Landewe R, et al. Nonsteroidal antiinflammatory drugs reduce radiographic progression in patients with ankylosing spondylitis: a randomized clinical trial. Arthritis Rheum. 2005 Jun. 52(6):1756-65. [Medline].\nSieper J, Klopsch T, Richter M, Kapelle A, Rudwaleit M, Schwank S, et al. Comparison of two different dosages of celecoxib with diclofenac for the treatment of active ankylosing spondylitis: results of a 12-week randomised, double-blind, controlled study. Ann Rheum Dis. 2008 Mar. 67(3):323-9. [Medline]. [Full Text].\nChen J, Liu C. Is sulfasalazine effective in ankylosing spondylitis? A systematic review of randomized controlled trials. J Rheumatol. 2006 Apr. 33(4):722-31. [Medline].\nClegg DO, Reda DJ, Weisman MH, Blackburn WD, Cush JJ, Cannon GW, et al. Comparison of sulfasalazine and placebo in the treatment of ankylosing spondylitis. A Department of Veterans Affairs Cooperative Study. Arthritis Rheum. 1996 Dec. 39(12):2004-12. [Medline].\nClegg DO, Reda DJ, Abdellatif M. Comparison of sulfasalazine and placebo for the treatment of axial and peripheral articular manifestations of the seronegative spondylarthropathies: a Department of Veterans Affairs cooperative study. Arthritis Rheum. 1999 Nov. 42(11):2325-9. [Medline].\nBraun J, Pavelka K, Ramos-Remus C, Dimic A, Vlahos B, Freundlich B, et al. Clinical efficacy of etanercept versus sulfasalazine in ankylosing spondylitis subjects with peripheral joint involvement. J Rheumatol. 2012 Apr. 39(4):836-40. [Medline].\nInman RD, Maksymowych WP. A double-blind, placebo-controlled trial of low dose infliximab in ankylosing spondylitis. J Rheumatol. 2010 Jun. 37(6):1203-10. [Medline].\nBraun J, Davis J, Dougados M, et al. First update of the international ASAS consensus statement for the use of anti-TNF agents in patients with ankylosing spondylitis. Ann Rheum Dis. 2006 Mar. 65(3):316-20. [Medline].\nBraun J, Baraliakos X, Golder W, et al. Magnetic resonance imaging examinations of the spine in patients with ankylosing spondylitis, before and after successful therapy with infliximab: evaluation of a new scoring system. Arthritis Rheum. 2003 Apr. 48(4):1126-36. [Medline].\nGorman JD, Sack KE, Davis JC Jr. Treatment of ankylosing spondylitis by inhibition of tumor necrosis factor alpha. N Engl J Med. 2002 May 2. 346(18):1349-56. [Medline].\nDavis JC, Van Der Heijde D, Braun J, et al. Recombinant human tumor necrosis factor receptor (etanercept) for treating ankylosing spondylitis: a randomized, controlled trial. Arthritis Rheum. 2003 Nov. 48(11):3230-6. [Medline].\nvan der Heijde D, Dijkmans B, Geusens P, et al. Efficacy and safety of infliximab in patients with ankylosing spondylitis: results of a randomized, placebo-controlled trial (ASSERT). Arthritis Rheum. 2005 Feb. 52(2):582-91. [Medline].\nBraun J, Landewé R, Hermann KG, et al. Major reduction in spinal inflammation in patients with ankylosing spondylitis after treatment with infliximab: results of a multicenter, randomized, double-blind, placebo-controlled magnetic resonance imaging study. Arthritis Rheum. 2006 May. 54(5):1646-52. [Medline].\nGengenbacher M, Sebald HJ, Villiger PM, Hofstetter W, Seitz M. Infliximab inhibits bone resorption by circulating osteoclast precursor cells in patients with rheumatoid arthritis and ankylosing spondylitis. Ann Rheum Dis. 2008 May. 67(5):620-4. [Medline].\nvan der Heijde D, Kivitz A, Schiff MH, et al. Efficacy and safety of adalimumab in patients with ankylosing spondylitis: results of a multicenter, randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2006 Jul. 54(7):2136-46. [Medline].\nInman RD, Davis JC Jr, Heijde D, Diekman L, Sieper J, Kim SI, et al. Efficacy and safety of golimumab in patients with ankylosing spondylitis: results of a randomized, double-blind, placebo-controlled, phase III trial. Arthritis Rheum. 2008 Nov. 58(11):3402-12. [Medline].\nMedscape News. FDA clears certolizumab (Cimzia) for ankylosing spondylitis. Medscape. Available at http://www.medscape.com/viewarticle/812822. Accessed: October 18, 2013.\nLandewé R, Braun J, Deodhar A, Dougados M, Maksymowych WP, Mease PJ, et al. Efficacy of certolizumab pegol on signs and symptoms of axial spondyloarthritis including ankylosing spondylitis: 24-week results of a double-blind randomised placebo-controlled Phase 3 study. Ann Rheum Dis. 2013 Sep 6. [Medline]. [Full Text].\nFurst DE, Breedveld FC, Kalden JR, Smolen JS, Burmester GR, Emery P, et al. Updated consensus statement on biological agents for the treatment of rheumatic diseases, 2006. Ann Rheum Dis. 2006 Nov. 65 Suppl 3:iii2-15. [Medline].\nKelly JC. Ankylosing Spondylitis: Prolonged Anti-TNF Stops Damage. Medscape Medical News. Jun 22 2013. Available at http://www.medscape.com/viewarticle/808219. Accessed: July 30, 2013.\nHaroon N, Inman RD, Learch TJ, Weisman MH, Lee M, Rahbar MH, et al. The Impact of TNF-inhibitors on radiographic progression in Ankylosing Spondylitis. Arthritis Rheum. 2013 Jul 1. [Medline].\nBaeten D, Sieper J, Braun J, Baraliakos X, Dougados M, Emery P, et al. Secukinumab, an Interleukin-17A Inhibitor, in Ankylosing Spondylitis. N Engl J Med. 2015 Dec 24. 373 (26):2534-48. [Medline].\nvan der Heijde D, Cheng-Chung Wei J, Dougados M, Mease P, Deodhar A, Maksymowych WP, et al. Ixekizumab, an interleukin-17A antagonist in the treatment of ankylosing spondylitis or radiographic axial spondyloarthritis in patients previously untreated with biological disease-modifying anti-rheumatic drugs (COAST-V): 16 week results of a phase 3 randomised, double-blind, active-controlled and placebo-controlled trial. Lancet. 2018 Dec 8. 392 (10163):2441-2451. [Medline].\nDeodhar A, Poddubnyy D, Pacheco-Tena C, Salvarani C, Lespessailles E, Rahman P, et al. Efficacy and Safety of Ixekizumab in the Treatment of Radiographic Axial Spondyloarthritis: Sixteen-Week Results From a Phase III Randomized, Double-Blind, Placebo-Controlled Trial in Patients With Prior Inadequate Response to or Intolerance of Tumor Necrosis Factor Inhibitors. Arthritis Rheumatol. 2019 Apr. 71 (4):599-611. [Medline]. [Full Text].\nChen J, Liu C, Lin J. Methotrexate for ankylosing spondylitis. Cochrane Database Syst Rev. 2006 Oct 18. CD004524. [Medline].\nvan Denderen JC, van der Paardt M, Nurmohamed MT, de Ryck YM, Dijkmans BA, van der Horst-Bruinsma IE. Double blind, randomised, placebo controlled study of leflunomide in the treatment of active ankylosing spondylitis. Ann Rheum Dis. 2005 Dec. 64(12):1761-4. [Medline].\n[Guideline] Ward MM, Deodhar A, Akl EA, et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2015 Sep 24. [Medline]. [Full Text].\n[Guideline] Smolen JS, Schöls M, Braun J, Dougados M, FitzGerald O, et al. Treating axial spondyloarthritis and peripheral spondyloarthritis, especially psoriatic arthritis, to target: 2017 update of recommendations by an international task force. Ann Rheum Dis. 2018 Jan. 77 (1):3-17. [Medline]. [Full Text].\nvan Denderen JC, Visman IM, Nurmohamed MT, Suttorp-Schulten MS, van der Horst-Bruinsma IE. Adalimumab significantly reduces the recurrence rate of anterior uveitis in patients with ankylosing spondylitis. J Rheumatol. 2014 Sep. 41(9):1843-8. [Medline].\nvan der Heijde D, Dougados M, Davis J, Weisman MH, Maksymowych W, Braun J, et al. ASsessment in Ankylosing Spondylitis International Working Group/Spondylitis Association of America recommendations for conducting clinical trials in ankylosing spondylitis. Arthritis Rheum. 2005 Feb. 52(2):386-94. [Medline].\nZochling J, Braun J. Assessments in ankylosing spondylitis. Best Pract Res Clin Rheumatol. 2007 Aug. 21(4):699-712. [Medline].\nZochling J. Assessment and treatment of ankylosing spondylitis: current status and future directions. Curr Opin Rheumatol. 2008 Jul. 20(4):398-403. [Medline].\nBlizzard DJ, Penrose CT, Sheets CZ, Seyler TM, Bolognesi MP, Brown CR. Ankylosing Spondylitis Increases Perioperative and Postoperative Complications After Total Hip Arthroplasty. J Arthroplasty. 2017 Mar 27. [Medline].\nDagfinrud H, Kvien TK, Hagen KB. The Cochrane review of physiotherapy interventions for ankylosing spondylitis. J Rheumatol. 2005 Oct. 32(10):1899-906. [Medline].\nDagfinrud H, Kvien TK, Hagen KB. Physiotherapy interventions for ankylosing spondylitis. Cochrane Database Syst Rev. 2008 Jan 23. CD002822. [Medline].\nZhao Q, Dong C, Liu Z, Li M, Wang J, Yin Y, et al. The effectiveness of aquatic physical therapy intervention on disease activity and function of ankylosing spondylitis patients: a meta-analysis. Psychol Health Med. 2019 Sep 2. 1-12. [Medline].\nGoodman SM, Zhu R, Figgie MP, Huang WT, Mandl LA. Short-term Total Hip Replacement Outcomes in Ankylosing Spondylitis. J Clin Rheumatol. 2014 Oct. 20(7):363-8. [Medline].\nHidding A, van der Linden S, Gielen X, et al. Continuation of group physical therapy is necessary in ankylosing spondylitis: results of a randomized controlled trial. Arthritis Care Res. 1994 Jun. 7(2):90-6. [Medline].\nKisacik B, Tufan A, Kalyoncu U, et al. Mean platelet volume (MPV) as an inflammatory marker in ankylosing spondylitis and rheumatoid arthritis. Joint Bone Spine. 2008 May. 75(3):291-4. [Medline].\nKraag G, Stokes B, Groh J, Helewa A, Goldsmith C. The effects of comprehensive home physiotherapy and supervision on patients with ankylosing spondylitis--a randomized controlled trial. J Rheumatol. 1990 Feb. 17(2):228-33. [Medline].\nThis 15-year-old female patient presented with recent onset of right-sided low back pain. Plain radiography findings were normal.\nMRI of the same patient whose radiography findings were normal (previous image). She underwent further evaluation, including MRI. The MRI (short tau inversion recovery [STIR]) showed increased sinal intensity in the right sacroiliac joint, revealing sacroiliitis. Other laboratory study findings were essentially normal. The patient was started on indomethacin and rapidly improved.\nPatient with ankylosing spondylitis affecting cervical and upper thoracic spine. Patient's spine has been fused in flexed position.\nPosterior view of patient with ankylosing spondylitis affecting cervical and upper thoracic spine. Patient's spine has been fused in flexed position.\nAnteroposterior radiograph of sacroiliac joint of patient with ankylosing spondylitis. Bilateral sacroiliitis with sclerosis can be observed.\nAnteroposterior radiograph of spine of patient with ankylosing spondylitis. Ossification of anulus fibrosus can be observed at multiple levels, which has led to fusion of spine with abnormal curvature.\nAnteroposterior radiograph of spine of patient with ankylosing spondylitis. Ossification of anulus fibrosus at multiple levels and squaring of vertebral bodies can be observed.\nAnteroposterior radiograph of spine of patient with ankylosing spondylitis.\nAnteroposterior (left) and lateral (right) radiographs of patient with ankylosing spondylitis.\nRadiographs of hand (top) and arm (bottom) of patient with peripheral involvement of ankylosing spondylitis. Fusion of joint spaces and deformity can be observed.\nSagittal MRI of thoracolumbar spine of a patient with ankylosing spondylitis. Degenerative disc disease and bridging osteophytes can be observed at multiple levels.\nRadiograph shows vertebral fracture in patient with ankylosing spondylitis.\nThis radiograph of the lumbar spine of a patient with end-stage ankylosing spondylitis shows bridging syndesmophytes, resulting in bamboo spine.\nThis radiograph of the cervical spine of a patient with ankylosing spondylitis shows fusion of vertebral bodies due to bridging syndesmophytes.\nASAS Classification Criteria for Axial Spondyloarthropathy.\nASAS Classification Criteria for Peripheral Spondyloarthropathy.\nFamily of spondyloarthropathies and HLA-B27 associated diseases\nTable 4. Clinical and Laboratory Features of Undifferentiated Spondyloarthropathy\nLawrence H Brent, MD Associate Professor of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center\nLawrence H Brent, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Physicians, American College of Rheumatology\nDisclosure: Stock ownership for: Johnson & Johnson.\nAnand Patel, MD Fellow, Department of Rheumatology, Temple University Hospital\nAnand Patel, MD is a member of the following medical societies: American College of Rheumatology, Pennsylvania Rheumatology Society, Philadelphia Rheumatism Society\nRuchika Patel, MD Attending Physician, Division of Rheumatology, Einstein Medical Center\nRuchika Patel, MD is a member of the following medical societies: American College of Physicians, American College of Rheumatology, Philadelphia Rheumatism Society\nHerbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital\nHerbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, Phi Beta Kappa\nRajni Kalagate, MD Resident Physician, Department of Internal Medicine, Albert Einstein Medical Center\nRajni Kalagate, MD is a member of the following medical societies: American Academy of Pediatrics, Indian Medical Association\nJason C Eck, DO, MS Assistant Professor, Department of Orthopedics and Physical Rehabilitation, UMass Memorial Medical Center\nJason C Eck, DO, MS is a member of the following medical societies: American Osteopathic Academy of Orthopedics, American Osteopathic Association, International Society for the Study of the Lumbar Spine, and North American Spine Society\nDisclosure: Medtronic Honoraria Speaking and teaching\nElliot Goldberg, MD Dean of the Western Pennsylvania Clinical Campus, Professor, Department of Medicine, Temple University School of Medicine\nElliot Goldberg, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, and American College of Rheumatology\nScott D Hodges, DO Consulting Surgeon, Department of Orthopedic Surgery, Center for Sports Medicine and Orthopedics\nScott D Hodges, DO is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Medical Association, American Osteopathic Association, American Spinal Injury Association, North American Spine Society, Southern Medical Association, Southern Orthopaedic Association, and Tennessee Medical Association\nDisclosure: Medtronic Royalty Consulting; Biomet Spine Royalty Consulting\nS Craig Humphreys, MD Orthopedic Spine Surgeon, Department of Orthopedic Surgery, Center for Sports Medicine and Orthopedics\nS Craig Humphreys, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Spinal Injury Association, North American Spine Society, Southern Medical Association, Southern Orthopaedic Association, and Tennessee Medical Association\nJames F Kellam, MD Vice-Chair, Department of Orthopedic Surgery, Director of Orthopedic Trauma and Education, Carolinas Medical Center\nJames F Kellam, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, and Royal College of Physicians and Surgeons of Canada\nKristine M Lohr, MD, MS Professor, Department of Internal Medicine, Center for the Advancement of Women's Health and Division of Rheumatology, Director, Rheumatology Training Program, University of Kentucky College of Medicine\nKristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians and American College of Rheumatology\nWilliam O Shaffer, MD Professor, Vice-Chairman and Residency Program Director, Department of Orthopedic Surgery, University of Kentucky at Lexington\nWilliam O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, International Society for the Study of the Lumbar Spine, Kentucky Medical Association, Kentucky Orthopaedic Society, North American Spine Society, Southern Medical Association, and Southern Orthopaedic Association\nDisclosure: DePuySpine 1997-2007 (not presently) Royalty Consulting; DePuySpine 2002-2007 (closed) Grant/research funds SacroPelvic Instrumentation Biomechanical Study; DePuyBiologics 2005-2008 (closed) Grant/research funds Healos study just closed; DePuySpine 2009 Consulting fee Design of Offset Modification of Expedium"